Provider Demographics
NPI:1831122399
Name:PAVILLARD, MICHELE A (DO)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:PAVILLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-2925
Mailing Address - Country:US
Mailing Address - Phone:607-936-1244
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:290 E 1ST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2925
Practice Address - Country:US
Practice Address - Phone:607-936-1244
Practice Address - Fax:607-936-4023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1866092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD98715Medicare UPIN
NYRA6465Medicare ID - Type Unspecified